Confidential Client Questionnaire

Instructions: Please complete this form to the best of your ability. Please leave blank any information that you do not know. Indicate N/A where not applicable. All information you provide is strictly confidential.

If you are taking medication which affects your ability to complete this form, or have a physical or mental injury which prevents you from completing this form, please tell us so we can accommodate your situation.

We are here to help you!

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Name*

First

Last

Address*

Street Address

Address Line 2

City

State

ZIP Code

Phone*

Email

Emergency contact (name)

Phone

Date of birth*

MM

DD

YYYY

Social Security Number*

Marital Status*

Spouse's name*

How did you hear about us?*

Who referred you?

Date of collision*

Date Format: MM slash DD slash YYYY

Time

HH:

MM

Location of collision

Please identify who you were:*

Was anyone with you?

First

Last

Did this incident happen on the job?

Yes

No

Briefly describe how the collision occurred

Were you wearing your seatbelt?

Yes

No

Were the police called?

Yes

No

Which police agency responded?

Tucson Police Department

Oro Valley Police Department

Marana Police Department

Pima County Sheriff’s Department

Arizona Department of Public Safety

What is the police report number (if known)?

Did anyone witness the collision?

Yes

No

Name

First

Last

Phone

Owner of the vehicle you were driving

First

Last

Briefly describe the damage to your vehicle

Your auto insurance company

Name of other person who caused this wreck

Other person's auto insurance company

Describe your injuries

Were you taken by ambulance?

Yes

No

Which hospital did you go to?

Location

Name of doctor you have seen regarding your injuries

First

Last

Name of doctor you have seen regarding your injuries

First

Last

Name of doctor you have seen regarding your injuries

First

Last

Have you lost time from work?

Yes

No

Employer

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Supervisor

First

Last

Supervisor's Phone Number

Job Title or Position

Rate of pay

Hours per week normally worked

Have you been involved in prior collision?

Have you ever filed a claim for Worker's Compensation?

Do you have medical/health insurance?

Who provides your health insurance?

What, if any, benefits are you currently receiving?

Social Security (Retirement)

Social Security Disability

Medicare

Supplemental Social Security

AHCCCS

Unemployment

TANF, food stamps

Have you filed bankruptcy within the past five years?

If so, when?

Do you intend on filing bankruptcy in the near future?

Do you have any documents you want us to see?

Please upload any photos, medical records, receipts, police reports, notes, or other documentation you would like us to have prior to our meeting.